Dennis Hartlieb
Predictable Esthetic Crown Lengthening
Predictable Esthetic Crown Lengthening
One of the challenges that I have experienced in the field of cosmetic dentistry is when I am working with a surgical colleague for esthetic crown lengthening cases. Now, just for clarification, esthetic crown lengthening is different than functional crown lengthening.
Functional crown lengthening is generally about creating enough tooth structure for the dentist to be able to predictably restore the tooth – to create ferrule. FCL is often be related to tooth fracture or deep caries, and the procedure can involve any, including all, of the surfaces of the root.
Esthetic crown lengthening, however, is typically related just to the facial, and sometimes interproximals, of the anterior teeth. While we may gain tooth structure for our restorative procedures, the goal of the crown lengthening is to set the gingival margin position in an improved esthetic position.
Functional crown lengthening is generally about creating enough tooth structure for the dentist to be able to predictably restore the tooth – to create ferrule. FCL is often be related to tooth fracture or deep caries, and the procedure can involve any, including all, of the surfaces of the root.
Esthetic crown lengthening, however, is typically related just to the facial, and sometimes interproximals, of the anterior teeth. While we may gain tooth structure for our restorative procedures, the goal of the crown lengthening is to set the gingival margin position in an improved esthetic position.
In the past, I would either create a surgical guide (vacuform with idealized cervical margin position created), or give measurements from the incisal edge of the tooth/teeth, to help the surgeon during the procedure.
Unfortunately, I have found the results to vary, I think mostly because it can be difficult for the surgeon to accurately gauge when measuring during the surgery. With the surgical guide, the fact that the guide is several millimeters away from the bone, angulation issues with the handpiece or chisel around the guide will influence the actual amount of bone removed.
Based on less than ideal results, I have designed a technique that I believe creates more control for the restorative dentist with these esthetic crown lengthening cases. The technique that I am sharing is the procedure I use when anterior teeth need crowns, or have existing crowns that need replacement.
Unfortunately, I have found the results to vary, I think mostly because it can be difficult for the surgeon to accurately gauge when measuring during the surgery. With the surgical guide, the fact that the guide is several millimeters away from the bone, angulation issues with the handpiece or chisel around the guide will influence the actual amount of bone removed.
Based on less than ideal results, I have designed a technique that I believe creates more control for the restorative dentist with these esthetic crown lengthening cases. The technique that I am sharing is the procedure I use when anterior teeth need crowns, or have existing crowns that need replacement.
Read also: Treatment Plan for Two Central Incisors
Importantly, this technique is applicable for those who do their own esthetic crown lengthening procedures, and for those who refer to surgical specialists, like their periodontists. The following is the protocol that I use in my office:
1- After records are taken of the patient (study cast impressions (analog or digital), x-rays, photographs, and facebow and centric bite recording for articulator mounting), the patient is rescheduled for provisionalization and gingivectomy.
2- A wax-up is completed on the mounted casts and a matrix is prepared for provisional fabrication at the patient’s next visit.
3- The patient is referred to the periodontist for evaluation for crown lengthening. Communication is critical with the restorative dentist and the periodontist to help the periodontist understand the staging of the patient’s treatment. The patient is scheduled for a surgical appointment with the periodontist 10-14 days after my next appointment with the patient.
4- At the next appointment with me (the restorative dentist), this is my workflow:
1- After records are taken of the patient (study cast impressions (analog or digital), x-rays, photographs, and facebow and centric bite recording for articulator mounting), the patient is rescheduled for provisionalization and gingivectomy.
2- A wax-up is completed on the mounted casts and a matrix is prepared for provisional fabrication at the patient’s next visit.
3- The patient is referred to the periodontist for evaluation for crown lengthening. Communication is critical with the restorative dentist and the periodontist to help the periodontist understand the staging of the patient’s treatment. The patient is scheduled for a surgical appointment with the periodontist 10-14 days after my next appointment with the patient.
4- At the next appointment with me (the restorative dentist), this is my workflow:
- The gingival tissue is dried and a ‘Sharpie’ marker is used to outline desired soft tissue contour changes prior to patient anesthesia. Photographs are taken and evaluated and discussed with the patient. If all agree on the proposed soft tissue change, the patient is anesthetized with a local anesthetic.
- A gingivectomy (GV) is performed to create the ideal height and contour to the soft tissue, preferably with the existing dentistry in place. The gingivectomy can be completed using electro-surgery, as I have in this treatment case, or it can be done with a soft tissue laser or a scalpel. The goal of this step is to idealize the soft tissue position, ignoring the bone height under the gum line. Invasion of biologic width is anticipated.
- The current restoration is removed and the tooth is prepared for the provisional crown, at the new gingival margin position. If build-ups are necessary, they are completed at this time.
- The provisional is fabricated and cemented.
5- The patient is seen post-operatively about 1 week after the GV. At this appointment, I am evaluating the soft tissue height and contour with the patient when they are no longer numb. The value of this appointment is that I can now give final instructions to my periodontist on what I want them to do at the upcoming surgical visit.
- If the soft tissue is ideal, I instruct the surgeon to reflect a flap, and reshape the bone so that there is a 3mm zone from the established provisional margin to the osseous crest to allow for the biologic width. Now, the surgeon may need to make changes based on clinical factors such as bone thickness (thin bone, err on less removal) and the root position (if the root is palatally positioned, more osseous recontouring may be necessary)
- If I did not remove enough soft tissue at my previous appointment, and the gingival margin of the provisional is too coronal, I will ask for increased osseous recontouring by the surgeon. However, I do not want the surgeon to remove the gum tissue – I personally want to control the soft tissue final position. If for instance, on my post-op evaluation I note that I should have resected the gum tissue an additional 1 mm to level the gingival margins, then I would have my surgeon osseous crown lengthen 4 mm, instead of 3 mm from the free gingival margin. After the patient has healed from the osseous surgery, and prior to final impressions, I will then go and trim the excess tissue away to create ideal contour and shape.
- If I took away too much soft tissue, then I would ask the surgeon to remove less bone, and also to reshape the facial contour of the provisional (flatten the facial emergence profile of the provisional.
6- The patient returns to my office 6-8 weeks later for evaluation. At this appointment, the tissue should look ideal, but typically not have a normal probable sulcus. At 4-6 months, I’ll have the patient return for gentle probing to see if the sulcus has renormalized. Only when the patient has a probable sulcus, without bleeding, can we move to impressions for definitive restorations.
In the treatment case provided, the patient was supposed to have the osseous surgery with my periodontist a couple of weeks after the provisionalization appointment. Unfortunately, the patient cancelled that appointment and lost contact with our practice. When she returned over a year later, the provisional had been recemented at another practice and there was a fracture on the distal incisal edge of the provisional. I counseled the patient on the procedure (again) and the patient was reappointed with both me, and the surgeon, for a new provisional (and GV) and follow-up osseous surgery with the periodontist. The patient insisted that she would follow thru with treatment this time.
The patient is currently in a holding pattern after her surgery - I’ll update her case when we move to the definitive restoration. I hope that this helps for those esthetic crown lengthening cases where there are provisionals to be placed…in the future, I’ll write a separate blog on cases where there won’t be restorative dentistry until after the crown lengthening and how I communicate with my surgeon for those situations.
That’s it for now – your for better dentistry,
Dennis Hartlieb, DDS, AAACD
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Meet Dr. Dennis Hartlieb
Dr. Dennis Hartlieb owns his own practice in Chicago,IL and has been teaching dentistry for over 30 years. Dr. Hartlieb is the CEO and the main instructor at Dental Online Training. He is an active member in the American Academy of Cosmetic Dentistry where he’s both an Accredited Member and Examiner for Accreditation.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Meet Dr. Angela Luek
Dr. Angela M. Lueck is a Wisconsin native and was the youngest female in her class from Marquette University in 1998. Since completing her residency she has consistently taken more than 100 hours a year of continuing education to keep current on the latest trends, techniques, and materials available in dentistry.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
Meet Clare O'Neill
Clare O’Neill is the Director of Operations at Dental Online Training and has a professional background in digital marketing. Clare has certifications in content marketing and digital advertising. Clare has expertise in social media marketing, email marketing, content marketing, website management, and project management. Clare has been using Canva for over 5 years and is a self-proclaimed Canva Queen.
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
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He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
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With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
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Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
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Meet Dr. Sofya Kats
Dr. Sofya Kats is local to Milwaukee, WI. She grew up in Bayside and attended Nicolet HS, UW-Milwaukee and Marquette University School of Dentistry. Dr. Kats is a member of the Greater Milwaukee Dental Association, Wisconsin Dental Association, American Dental Association, and The Forum Study Club (oldest Dental Study Club in the United States).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).